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OPEN Association between serum uric

acid levels and mortality:
a nationwide community-based
cohort study
Tsuneo Konta1*, Kazunobu Ichikawa2, Ryo Kawasaki3, Shouichi Fujimoto4, Kunitoshi Iseki4,
Toshiki Moriyama4, Kunihiro Yamagata 4, Kazuhiko Tsuruya4, Ichiei Narita4,
Masahide Kondo4, Yugo Shibagaki4, Masato Kasahara4, Koichi Asahi4 & Tsuyoshi Watanabe4
Hyperuricemia is associated with all-cause and cardiovascular mortality. However, the threshold value
of serum uric acid levels for increased risk of mortality has not been determined. This large-scale cohort
study used a nationwide database of 500,511 Japanese subjects (40–74 years) who participated in
the annual health checkup and were followed up for 7 years. The association of serum uric acid levels
at baseline with cardiovascular and all-cause mortality was examined. The Cox proportional hazard
model analysis with adjustment for possible confounders revealed that the all-cause and cardiovascular
mortality showed a J-shaped association with serum uric acid levels at baseline in both men and women.
A significant increase in the hazard ratio for all-cause mortality was noted with serum uric acid levels
≥ 7 mg/dL in men and ≥ 5 mg/dL in women. A similar trend was observed for cardiovascular mortality.
This study disclosed that even a slight increase in serum uric acid levels was an independent risk factor
for all-cause and cardiovascular mortality in both men and women in a community-based population.
Moreover, the threshold values of uric acid for mortality might be different for men and women.

Hyperuricemia is an established risk factor for gout and end-stage kidney disease1. Furthermore, various studies
have suggested the association of hyperuricemia with all-cause and cardiovascular mortality2–9. However, the
definition of hyperuricemia varies in each study; therefore, the threshold value of serum uric acid for increased
risk of mortality, which is essential for the initiation of treatment, has not been determined.
When examining the association between uric acid levels and prognosis, several points must be considered.
First, hyperuricemia is often accompanied by other risk factors such as hypertension, obesity, diabetes, dyslipi-
demia, and renal insufficiency. This makes it difficult to determine whether hyperuricemia is an independent
risk factor or a mere bystander with the other risk factors. Second, sex differences in the distribution of serum
uric acid levels exist, and this may modify the association between serum uric acid levels and mortality10–12.
Third, some studies showed that the association between serum uric levels and mortality was not linear, but
J-shaped11–13, indicating that the conventional classification of uric acid levels, such as hyperuricemia (e.g., >
7 mg/dL) or per 1 mg/dL increase, might be inappropriate to evaluate the risk of increased serum uric acid levels
on mortality.
Considering these conditions, a large-scale study with a sufficient number of events, various correction fac-
tors, and a sex-specific reference range of uric acid is necessary to address this issue. However, in most previous
studies, the conventional classification or quartile/quintile subgrouping of uric acid was used, and the number of
events was insufficient to perform a multivariate analysis using a fine classification of uric acid levels. Accordingly,
the association between uric acid levels and mortality remains unclear.

1
Department of Public Health and Hygiene, Yamagata University School of Medicine, Yamagata, Japan. 2Department
of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan. 3Department
of Vision Informatics (Topcon), Osaka University Graduate School of Medicine, Osaka, Japan. 4Steering Committee
of Research on Design of the Comprehensive Health Care System for Chronic Kidney Disease (CKD) Based on the
Individual Risk Assessment by Specific Health Checkup, Fukushima, Japan. *email: [email protected]

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To clarify the threshold values of uric acid levels for increased risk for all-cause and cardiovascular mortality,
this study retrieved a database of 500,511 community-based Japanese participants with 5,578 mortality events
from a nationwide prospective cohort study.

Methods
Study population. This study was part of an ongoing “Research on design of the comprehensive health care
system for chronic kidney disease (CKD) based on individual risk assessment by Specific Health Checkup” study.
The Specific Health Check and Guidance is an annual health checkup for all inhabitants of Japan between 40 and
74 years and is covered by the Japanese national health insurance. We utilized databases obtained from 7 areas:
Fukushima, Niigata, Ibaraki, Toyonaka, Fukuoka, Miyazaki, and Okinawa. Data were collected from 664,926 sub-
jects (male: 284,320; female: 380,606; age: 40–74 years) who participated in the baseline health checkups between
2008 and 2014. The study was conducted in accordance with the guideline of the Declaration of Helsinki and was
granted ethical approval by the ethics committees of Yamagata University (Approval No. 2008-103). The ethics
committees of Yamagata University waived the need for informed consent from each participant because all data
were anonymized before analysis. The details of this study have been described elsewhere14,15.
Among the 664,926 participants, 164,415 participants (male: 68,592; female: 95,823) were excluded from
this study because some essential data, including serum uric acid levels, were incomplete. Therefore, data from
500,511 subjects (male: 215,728; female: 284,783; age: 40–74 years) were included in this analysis. The association
between serum uric acid levels at baseline and all-cause and cardiovascular mortality during the 7-year follow-up
period (median 3.6 years) was examined.

Measurements. The subjects completed a self-report questionnaire to document their medical history, cur-
rent medications, smoking habits (smoker or non-smoker), and alcohol consumption (drinker or non-drinker).
Systolic (SBP) and diastolic blood pressure were measured using a standard sphygmomanometer or an auto-
mated device, with subjects in a sitting position. Body mass index (BMI) was calculated as weight in kilograms
(kg) divided by the square of the height (m2). Plasma glucose levels were mainly measured using the hexokinase
enzymatic reference method. Triglyceride and low-density lipoprotein cholesterol (LDL-C) concentrations were
measured using enzymatic methods, and high-density lipoprotein cholesterol (HDL-C) concentrations were
measured directly. Serum uric acid levels were mainly measured using an enzymatic method, and hyperuricemia
was defined as serum uric acid levels >7 mg/dL. Serum creatinine was measured by an enzymatic method, and
the estimated glomerular filtration rate (eGFR) was obtained using the Japanese equation16. All blood and urine
analyses were performed in local laboratories. The methods for these analyses were not calibrated between labora-
tories; however, the analyses were performed according to the Japan Society of Clinical Chemistry recommended
methods for laboratory tests, which have been widely adopted by laboratories across Japan. The measured items
and the disease criteria in this study are based on the methods used in our previous studies10,14.
The incidence of death was monitored annually at the end of 2015, and the causes of death were determined by
reviewing death certificates until 2015. Death certificates of the deceased participants were collected with permis-
sion from the Management and Coordination Agency of the Japanese government. The death code (International
Classification of Diseases, 10th Revision) and date of death were reviewed.

Statistical analysis. The chi-squared test was used to evaluate differences in proportions. To compare the
mean values among the groups, a one-way analysis of variance was conducted. To examine the factors related
to mortality, Kaplan–Meier and multivariate Cox proportional hazard analyses were performed. Moreover,
adjustment for possible confounding factors such as age, smoking habits, alcohol consumption, eGFR, BMI, SBP,
HbA1c (NGSP), triglyceride levels, LDL-C and HDL-C levels, and the use of antihypertensive, anti-diabetic, and
lipid-lowering medications was performed. The group with the lowest hazard ratio (HR) for mortality was used
as a reference. To confirm the association, a sensitivity analysis was performed in 428,347 subjects with preserved
renal function (eGFR ≥ 60 mL/min/1.73 m2) and in 349,906 subjects not taking any antihypertensive medica-
tions. Continuous data are expressed as the mean ± standard deviation. All statistical analyses were performed
using the JMP version 10 software (SAS Institute Inc., Cary, NC, USA) and Stata version 14 software (Stata Corp
LP, College Station, TX, USA). A P value < 0.05 was considered statistically significant.

Results
The subjects’ clinical characteristics at baseline are presented in Table 1. The mean age was 62 years in both men
and women, and the mean serum uric acid level was 6.1 mg/dL and 4.7 mg/dL, respectively. Both male and female
subjects with higher serum uric acid levels were more likely to be taking antihypertensive and lipid-lowering
medications, and to show a higher prevalence of smoking and alcohol consumption, higher values of BMI, SBP,
triglyceride, and LDL-C, and lower values of eGFR and HDL-C. Among subjects with higher serum uric acid
levels, the mean age, HbA1c, and prevalence of anti-diabetic medication were lower in men than in women.
During the 7-year follow-up period, 5,578 deaths were noted (1.1%) (men: 3,749 [1.7%]; women: 1,829
[0.6%]), including 1,104 deaths (0.2%) (men: 762 [0.4%]; women: 342 [0.1%]) due to cardiovascular causes.
To examine the association between serum uric acid levels and mortality, we performed a Kaplan–Meier anal-
ysis. The results showed that all-cause and cardiovascular mortality were high in both men and women with high
serum uric acid levels (log-rank P = 0.01) (Fig. 1). Then, a Cox proportional hazard analysis was performed. First,
the association of a 1 mg/dL increase in uric acid levels at baseline with all-cause and cardiovascular mortality
was examined (Table 2). In the unadjusted model, the HR for each 1 mg/dL increase in serum uric acid level and
all-cause and cardiovascular mortality increased in both men and women. Similarly, in the multivariate model
adjusted for possible confounders, a significant increase in the HR for all-cause mortality was observed for both
men and women (HR: 1.06; 95% confidence interval [CI]: 1.04–1.07 for all-cause mortality and HR: 1.07; 95% CI:

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Serum uric acid (mg/dL)

Men Total ≤ 2.9 3.0-3.9 4.0-4.9 5.0-5.9 6.0-6.9 7.0-7.9 8.0-8.9 > 9.0 P value
Number 215,728 1,992 9,449 30,383 60,311 61,317 34,764 12,605 4,907
Age (years) 62.2 ± 9.2 63.2 ± 8.8 63.8 ± 8.3 63.3 ± 8.5 62.7 ± 8.9 62.0 ± 9.3 61.3 ± 9.5 60.2 ± 9.7 59.4 ± 9.9 <0.01
Smoker (%) 27.3 28.4 27.7 27.8 27.1 26.8 27.0 28.6 32.1 <0.01
Alcohol consumption (%) 69.9 60.6 64.1 64.6 67.6 71.5 74.3 77.4 79.7 <0.01
Body Mass Index (kg/m2) 24.0 ± 3.2 23.0 ± 3.3 23.0 ± 3.2 23.1 ± 3.1 23.6 ± 3.1 24.2 ± 3.1 24.8 ± 3.3 25.2 ± 3.5 25.3 ± 3.7 <0.01
eGFR (ml/min/1.73m2) 74.9 ± 17.7 84.8 ± 23.9 82.8 ± 24.6 80.2 ± 17.5 76.9 ± 16.7 73.5 ± 16.2 70.5 ± 16.8 68.1 ± 16.7 65.0 ± 18.6 <0.01
Systolic blood pressure
130.9 ± 17.2 128.4 ± 17.1 129.4 ± 17.1 129.2 ± 17.3 129.9 ± 17.1 131.2 ± 16.9 132.6 ± 17.1 134.0 ± 17.6 134.5 ± 18.3 <0.01
(mmHg)
HbA1c (NGSP) (%) 5.8 ± 0.9 6.2 ± 1.6 6.1 ± 1.4 5.9 ± 1.2 5.8 ± 0.9 5.7 ± 0.7 5.7 ± 0.7 5.7 ± 0.6 5.7 ± 0.7 <0.01
Triglycerides (mg/dL) 143.5 ± 112.7 119.4 ± 85.5 119.2 ± 90.2 122.2 ± 94.8 129.5 ± 91.7 144.5 ± 105.3 164.8 ± 129.4 189.9 ± 157.1 221.1 ± 198.4 <0.01
HDL-cholesterol (mg/dL) 56.5 ± 15.2 58.8 ± 16.1 58.6 ± 15.6 58.2 ± 15.7 57.1 ± 15.0 56.1 ± 14.9 55.0 ± 15.1 54.3 ± 14.8 53.5 ± 14.9 <0.01
LDL-cholesterol (mg/dL) 120.3 ± 31.0 114.1 ± 30.4 116.3 ± 29.8 117.6 ± 29.9 119.8 ± 29.8 121.3 ± 30.6 122.3 ± 32.2 122.6 ± 34.1 120.2 ± 37.8 <0.01
Antihypertensive
33.3 28.5 29.2 28.8 30.6 35.2 37.8 36.8 38.5 <0.01
medication (%)
Antidiabetic medication
8.7 12.1 11.9 10.6 7.9 6.7 6.0 5.2 5.7 <0.01
(%)
Lipid lowering medication
10.8 12.1 11.2 10.9 10.8 11.1 10.8 9.2 9.1 <0.01
(%)
Serum uric acid (mg/dL)
Women P value
Total ≤ 2.9 3.0-3.9 4.0-4.9 5.0-5.9 6.0-6.9 7.0-7.9 8.0- > 9.0
Number 284,783 11,753 59,448 107,025 72,205 25,762 6,625 1,474 491
Age (years) 62.4 ± 8.7 61.0 ± 9.8 61.3 ± 9.4 62.2 ± 8.7 63.2 ± 8.1 63.7 ± 7.8 63.7 ± 7.9 64.5 ± 7.8 63.9 ± 8.4 <0.01
Smoker (%) 6.5 6.6 6.2 6.0 6.7 7.8 9.7 10.7 10.6 <0.01
Alcohol consumption (%) 28.9 25.7 26.5 28.8 30.3 31.1 32.5 33.7 28.2 <0.01
Body Mass Index (kg/m2) 23.0 ± 3.6 21.6 ± 3.2 21.8 ± 3.1 22.6 ± 3.3 23.8 ± 3.7 25.0 ± 4.0 25.9 ± 4.4 26.1 ± 4.5 25.8 ± 5.1 <0.01
eGFR (ml/min/1.73m2) 76.6 ± 17.2 85.9 ± 19.6 82.4 ± 17.3 77.5 ± 16.1 73.1 ± 15.6 69.0 ± 16.5 64.9 ± 17.6 58.9 ± 20.3 54.8 ± 24.3 <0.01
Systolic blood pressure
127.4 ± 17.7 124.3 ± 17.7 124.5 ± 17.7 126.5 ± 17.6 129.2 ± 17.4 131.7 ± 17.1 133.3 ± 17.5 133.7 ± 18.6 134.5 ± 18.6 <0.01
(mmHg)
HbA1c (NGSP) (%) 5.7 ± 0.7 5.7 ± 1.0 5.6 ± 0.7 5.7 ± 0.6 5.7 ± 0.6 5.8 ± 0.6 5.9 ± 0.7 5.9 ± 0.8 5.9 ± 0.8 <0.01
Triglycerides (mg/dL) 112.8 ± 68.4 93.7 ± 50.8 97.0 ± 53.9 107.1 ± 61.7 122.2 ± 71.6 139.6 ± 85.6 155.7 ± 101.5 175.4 ± 118.8 173.9 ± 120.6 <0.01
HDL-cholesterol (mg/dL) 64.8 ± 15.8 68.0 ± 15.5 67.4 ± 15.6 65.7 ± 15.6 63.1 ± 15.6 60.4 ± 15.5 58.5 ± 15.9 57.1 ± 15.9 57.5 ± 17.6 <0.01
LDL-cholesterol (mg/dL) 129.1 ± 31.2 122.3 ± 30.0 125.1 ± 30.0 128.8 ± 30.7 131.9 ± 31.5 133.7 ± 32.8 133.0 ± 33.5 132.0 ± 36.6 129.2 ± 37.7 <0.01
Antihypertensive
27.6 18.6 19.3 23.9 32.9 43.2 52.4 58.9 58.2 <0.01
medication (%)
Antidiabetic medication
4.2 4.3 3.6 3.6 4.3 6.0 7.4 9.4 9.8 <0.01
(%)
Lipid lowering medication
17.7 14.5 14.4 16.7 19.9 22.6 24.7 26.7 25.3 <0.01
(%)

Table 1. Baseline characteristics of the study population.

1.05–1.09 for cardiovascular mortality; and HR: 1.05 95% CI 1.03–1.08 for all-cause mortality and HR: 1.07; 95%
CI 1.03–1.11 for cardiovascular mortality, respectively).
Next, to clarify the threshold values of serum uric acid levels for mortality, the association between the fine
categories of serum uric acid levels and mortality was examined using the uric acid group with the lowest HR
for mortality (4.0–4.9 mg/dL in both males and females, except 6.0–6.9 mg/dL in the unadjusted analysis for
all-cause mortality in men) (Table 3). In the unadjusted model, the HR for all-cause and cardiovascular mortality
was higher in the group with high and low serum uric acid levels in both men and women than in the reference
group. In the multivariate model adjusted for the abovementioned confounders, a similar J-shaped independent
association of serum uric acid levels with all-cause and cardiovascular mortality was observed. A significant
increase in adjusted HR for all-cause mortality was observed with uric acid levels ≥7.0 mg/dL and <3.0 mg/dL
in men, and with levels ≥5.0 mg/dL and <3.0 mg/dL in women. Additionally, a significant increase in adjusted
HR for cardiovascular mortality was observed with levels ≥7.0 mg/dL and <3 mg/dL in men, and with levels of
5.0–5.9 and ≥7.0 mg/dL in women. The lowest values of adjusted HR for all-cause and cardiovascular mortality
were observed in both men and women with uric acid levels of 4.0–4.9 mg/dL.
In an additional analysis using the conventional cut-off point for hyperuricemia (>7.0 mg/dL), the adjusted
HRs of hyperuricemia (>7.0 mg/dL) for all-cause and cardiovascular mortality significantly increased.
Furthermore, the HRs were higher in women than in men (1.39; 95% CI: 1.28–1.51 and 1.68; 95% CI: 1.41–2.00
in men vs. 1.95; 95% CI: 1.54–2.47 and 2.49; 95% CI: 1.57–3.93 in women).
Finally, a sensitivity analysis was performed for confirmation among 428,347 subjects with preserved renal
function (eGFR ≥ 60 mL/min/1.73 m2) and 349,906 subjects not taking antihypertensive medications. The results
were almost identical (Supplementary Tables 1 and 2).

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Figure 1. Comparison of 7-year all-cause and cardiovascular mortality according to serum uric acid levels
between men and women.

All-cause mortality Cardiovascular mortality

Unadjusted HR Adjusted HR Unadjusted HR Adjusted HR
(95%CI) P value (95%CI)* P value (95%CI) P value (95%CI)* P value
Men 1.02 (0.996–1.04) 0.11 1.06 (1.04–1.07) <0.01 1.06 (1.04–1.08) <0.01 1.07 (1.05–1.09) <0.01
Women 1.07 (1.05–1.09) <0.01 1.05 (1.03–1.08) <0.01 1.09 (1.06–1.11) <0.01 1.07 (1.03–1.11) <0.01

Table 2. Hazard ratios for mortality per 1 mg/dL increase in the serum uric acid levels at baseline. *Adjusted
for age, body mass index, smoking, alcohol consumption, eGFR, systolic blood pressure, HbA1c (NGSP),
triglycerides, HDL-cholesterol, LDL-cholesterol, antihypertensive medication, antidiabetic medication, lipid-
lowering medication. eGFR; estimated glomerular filtration rate, HR; hazard ratio, CI; confidence interval.

Discussion
In this large-scale cohort study, we demonstrated a J-shaped association of serum uric acid levels with all-cause
and cardiovascular mortality after adjustment for confounders in a community-based population. A significant
increase in the risk for all-cause and cardiovascular mortality was observed in men with serum uric acid levels ≥7.0
and <3.0 mg/dL and in women with levels ≥5.0 and <3.0 mg/dL. Moreover, a similar trend was observed for
cardiovascular mortality in both men and women, indicating the different threshold values of uric acid levels for
mortality among men and women.
Some previous studies reported the sex-specific threshold values of uric acid for all-cause mortality: uric
acid levels ≥8.5 mg/dL in a male population in Japan (n = 49,413)17 and Korea (n = 207,167)11 and ≥7.5 mg/
dL in a female population in Korea (n = 167,996)11. The current study revealed that the threshold values of uric
acid levels for all-cause mortality (≥7.0 mg/dL in men and ≥5.0 mg/dL in women) are lower than the previously
reported values10,11,17. Similarly, a significant increase in the HR for cardiovascular mortality was detected at a
lower value in the current study (≥7.0 mg/dL in men and 5.0–5.9 and ≥7.0 mg/dL in women) than in the previ-
ous study (≥9.5 mg/dL in men and ≥8.5 mg/dL in women)11. This observation indicates that the current study,
which included a larger number of participants and events, could detect a slight but significant increase in uric
acid-related risk for mortality, and that the sex-specific threshold values of serum uric acid level for mortality
might be lower than previously reported.

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Serum uric acid (mg/dL) All-cause mortality Cardiovascular mortality

No. of Unadjusted HR Adjusted HR No. of Unadjusted HR Adjusted HR
Men (No. of subjects) events (95%CI) P value (95%CI)* P value events (95%CI) P value (95%CI)* P value
<2.9 (1,992) 57 1.86 (1.42–2.43) <0.01 1.49 (1.12–1.98) <0.01 13 2.47 (1.38–4.44) <0.01 2.51 (1.36–4.62) <0.01
3.0–3.9 (9,449) 210 1.42 (1.22–1.64) <0.01 1.15 (0.97–1.36) 0.10 31 1.19 (0.78–1.81) 0.42 1.22 (0.79–1.87) 0.37
4.0–4.9 (30,383) 554 1.17 (1.05–1.30) <0.01 reference 82 reference reference
5.0–5.9 (60,311) 1,013 1.08 (0.99–1.18) 0.10 1.06 (0.95–1.19) 0.26 193 1.19 (0.92–1.55) 0.19 1.29 (0.98–1.69) 0.07
6.0–6.9 (61,317) 946 reference 1.06 (0.95–1.19) 0.30 189 1.16 (0.89–1.50) 0.27 1.22 (0.92–1.62) 0.17
7.0–7.9 (34,764) 539 1.01 (0.91–1.13) 0.81 1.18 (1.04–1.35) 0.01 133 1.49 (1.10–1.91) <0.01 1.72 (1.27–2.32) <0.01
8.0–8.9 (12,605) 254 1.34 (1.16–1.54) <0.01 1.70 (1.45–2.00) <0.01 72 2.22 (1.62–3.06) <0.01 2.58 (1.81–3.66) <0.01
> 9.0 (4,907) 176 2.44 (2.08–2.87) <0.01 3.11 (2.58–3.76) <0.01 49 3.88 (2.72–5.55) <0.01 3.99 (2.63–6.04) <0.01
Hyperuricemia (>7 mg/dL)
891 1.14 (1.05–1.23) <0.01 1.39 (1.28–1.51) <0.01 234 1.62 (1.39–1.89) <0.01 1.68 (1.41–2.00) <0.01
(47,443)
No. of Unadjusted HR Adjusted HR No. of Unadjusted HR Adjusted HR
Women (No. of subjects) P value P value P value P value
events (95%CI) (95%CI)* events (95%CI) (95%CI)*
<2.9 (11,753) 103 1.57 (1.27–1.93) <0.01 1.52 (1.22–1.90) <0.01 15 1.49 (0.87–2.58) 0.15 1.53 (0.87–2.73) 0.14
3.0–3.9 (59,448) 358 1.07 (0.94–1.23) 0.28 1.05 (0.91–1.21) 0.51 61 1.20 (0.87–1.67) 0.26 1.13 (0.80–1.61) 0.49
4.0–4.9 (107,025) 592 reference reference 90 reference reference
5.0–5.9 (72,205) 461 1.19 (1.05–1.35) 0.01 1.20 (1.06–1.37) <0.01 108 1.80 (1.36–2.89) <0.01 1.71 (1.27–2.30) <0.01
6.0–6.9 (25,762) 208 1.58 (1.35–1.86) <0.01 1.50 (1.26–1.78) <0.01 40 1.99 (1.37–2.89) <0.01 1.52 (1.00–2.30) 0.051
7.0–7.9 (6,625) 65 1.99 (1.54–2.58) <0.01 1.85 (1.40–2.46) <0.01 15 3.00 (1.74–5.18) <0.01 1.93 (1.01–3.68) 0.047
> 8.0 (1,965) 42 4.53 (3.30–6.22) <0.01 3.84 (2.68–5.52) <0.01 13 9.31 (5.20–16.6) <0.01 6.45 (3.32–12.5) <0.01
Hyperuricemia (>7 mg/dL)
90 2.17 (1.75–2.69) <0.01 1.95 (1.54–2.47) <0.01 26 3.48 (2.33–5.19) <0.01 2.49 (1.57–3.93) <0.01
(7,359)

Table 3. Hazard ratios for mortality by the serum uric acid levels at baseline. *Adjusted for age, body mass
index, smoking, alcohol consumption, eGFR, systolic blood pressure, HbA1c (NGSP), triglycerides, HDL-
cholesterol, LDL-cholesterol, antihypertensive medication, antidiabetic medication, lipid-lowering medication.
eGFR; estimated glomerular filtration rate, HR; hazard ratio, CI; confidence interval.

Of note, based on the current finding, a substantial number of men (serum uric acid levels ≥7.0 mg/dL
[24.2%]) and women (serum uric acid levels ≥5.0 mg/dL [37.4%]) are at a higher risk for mortality. However,
whether all high-risk subjects require uric acid-lowering medication remains unclear. This should be determined
based on the causality and cost-effectiveness of intervention trials.
Several possible mechanisms regarding how an excess of uric acid leads to mortality have been suggested. An
experimental study showed that oxygen radicals produced during the oxidation of xanthine and hypoxanthine
by xanthine oxidase may damage endothelial cells18. Another study revealed that uric acid, which is directly
absorbed in vascular endothelial cells, causes inflammation, resulting in endothelial dysfunction19,20. However,
further experimental studies are necessary to clarify the precise mechanism.
The J-shaped association between serum uric acid levels, and mortality and cardiovascular events was
observed in previous studies11,12,14 and the current study, suggesting that an extremely low serum uric acid level
may be another risk factor for all-cause and cardiovascular mortalities. There are several explanations for this
association. One is that low serum uric acid levels merely reflect the malnutrition status. In addition, uric acid
plays a protective role as an antioxidant in some conditions21. Further, there is a possibility that low serum uric
acid levels were partly due to the treatment with uric acid lowering agents, and such a background factor might
affect the mortality in the subjects with low serum uric acid levels. These points should be clarified in further
studies.
In general, men have higher serum uric acid levels than women, probably due to the higher volume of muscle
mass and the effect of sex hormones. However, the current study demonstrated that the lowest HR for mortality
was observed in subjects with uric acid levels of 4.0–4.9 mg/dL, among both men and women, after adjusting for
possible confounders. This observation suggests that the optimal levels of serum uric acid might be the same in
men and women. Hyperuricemia is generally defined as a serum uric acid level >7.0 mg/dL regardless of gender.
Such high levels of serum uric acid are common in men, but rare in women. This indicates that the presence of
hyperuricemia in women reflects the greatly impaired balance of uric acid metabolism and that the significance
of hyperuricemia is higher in women than in men.
The strength of this study is its large sample size, which allowed for analyses using the fine classification of
uric acid levels, with sufficient events, and the inclusion of various correction factors. In addition, we performed
a sensitivity analysis after excluding subjects with renal insufficiency and those on antihypertensive medication,
which increases the robustness of the study findings. However, this study has several limitations. First, the serum
uric acid levels were measured only at baseline. Second, there was no information on medication use for hyperu-
ricemia and others (i.e., diuretics) in this population. Third, the observational study did not show a direct causal
relationship between uric acid levels and cardiovascular disease. Clinical trials utilizing interventions through
uric acid-lowering therapy will clarify this point in the future.

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Conclusions
This study indicates that even a slight increase in serum uric acid levels was independently associated with
all-cause and cardiovascular mortality in a community-based population and that the sex-specific threshold val-
ues of serum uric acid for these adverse outcomes might be lower than previously reported values. To verify
our findings on the association between uric acid and mortality, a prospective interventional study using uric
acid-lowering therapies is warranted.

Data availability
The dataset analysed in this study are not available due to ethical reasons.

Received: 5 August 2019; Accepted: 25 March 2020;

Published: xx xx xxxx

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Acknowledgements
This study was supported by a Health and Labour Sciences Research Grant for “Design of the comprehensive
health care system for chronic kidney disease (CKD) based on the individual risk assessment by Specific Health
Checkup” from the Ministry of Health, Labour and Welfare of Japan and a Grant-in-Aid for “Research on
Advanced Chronic Kidney Disease (REACH-J), Practical Research Project for Renal Disease” from Japan Agency
for Medical Research and Development (AMED).

Author contributions
T.K. and K.I. conceived and designed the study concept and wrote the draft of the paper. T.K. and R.K. analyzed
the data. All authors contributed in writing and reviewing the paper substantively.

Competing interests
The authors declare no competing interests.

Additional information
Supplementary information is available for this paper at https://doi.org/10.1038/s41598-020-63134-0.
Correspondence and requests for materials should be addressed to T.K.
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